Clinical Treatment of Cannibas Use Disorders in Adolescents August 10, 2015 San Francisco Medicine Physician, Cannabis Use Disorders, Peter Banys, San Francisco Medicine, Timmen Cermak 0 By Peter Banys, MD, MSc and Timmen Cermak, MD Note: This article was originally published in the July/August 2015 issue of San Francisco Medicine. At this time in history, there are few organized treatment resources for adults and adolescents in trouble with marijuana. There is actually more need for treatment, especially for youth, than there are available treatment programs. This briefing summarizes the options and challenges for physicians working with their most severely affected adolescent patients with cannabis use disorders (CUD). It is our thesis that young-onset marijuana users are at greatest risk because, during school years, they are particularly vulnerable to many kinds of psychosocial disruptions that impact education and learning. A minority of regular (ten to nineteen days per month) and heavy (at least twenty days per month) users may also transition to meeting criteria for dependence for some period of time. For the most part, research outcomes studies have tested the same treatment methods that have been previously developed for other addictive drugs, including twelve-step meetings, psychotherapy, cognitive-behavioral treatments, and motivational interviewing. Youth studies rightly favor approaches that include a strong family component. All appear to produce moderate short-term benefits and significant rates of relapse. And, although a number of pharmaceuticals have been tested to reduce craving and/or relapse, none have been approved for use in cannabis dependence or withdrawal. Natural History of Cannabis Use Marijuana use, even heavy use, is not the same as problematic CUD. For most youthful users, marijuana dependence will be a self-limiting process. Unfortunately, only a few studies describe the transition from regular recreational use to dependent use. Although heavy users of marijuana are at higher risk for CUD, especially if they initiate use in the early teen years, the majority do not go on to a lifelong course of addiction. Most teens will transition out to low or no regular use in their twenties and thirties. Approximately 3.9 percent of recent-onset users will develop dependence within twenty-four months of first onset of use. Risks for dependence increase for onset before late adolescence, for low income, and for polydrug use prior to cannabis initiation. As of 2015 in California, before any legalization initiative, 8 percent of high school juniors are already heavy users, using marijuana twenty or more days each month, and another 3 percent are regular users, using ten to nineteen days each month. Marijuana use is one of many factors that is clearly associated with decrements in school performance. At present it is not possible to tease out relative causality among other associated factors, such as alcohol and drug use, family and peer-group effects, and culture. We believe that risks to educational progress are much greater than risks for persistent addiction or brain damage. Therapeutic Options California offers few public resources for treatment of severe cannabis addiction. Fewer treatment facilities specialize in adolescent treatment of substance abuse. One example is Thunder Road Adolescent Treatment Center in Oakland, but most such programs are unstably funded. For-profit residential substance abuse facilities developed for adults, often structured with spa-like amenities, sometimes offer residential tracks for adolescents. Their costs can be astonishingly high, and their longer-term outcomes are poorly documented. What is mostly missing are group support systems in the home community capable of providing flexible outpatient alternatives. For teens from families with means, one treatment option is a month or more in a wilderness program, most of which are in remote rural settings (to interfere with running away). Such programs offer extended forced separations from family and peers and emphasize self-reliance activities, such as camping, to foster a greater sense of responsibility and altruistic activities, such as peer collaboration. They are something of a blend of Outward Bound, ropes courses, and boot camp—all in the service of socialization into recovery and abstinence. This is, of course, only an initiation of treatment. Sustained treatment support remains difficult to find, in part because so little is offered within the school system. Those with insurance may turn to pediatricians or child psychiatrists, who typically only offer individual counseling, often with no expertise in addiction. The juvenile justice system remains a major provider of services for youth without means, but outcomes data are hard to find. The California Department of Corrections and Rehabilitation (CDCR) provides education, training, and treatment services for California's most serious youth offenders. Most of these substance abuse services are actually offered as part of a community-based probation system. Many juvenile marijuana arrests in fact are plea-bargained and more likely lead to probation than incarceration. There are several comprehensive reviews of treatment for cannabis use disorder. Five forms of treatment offered in several combinations have been studied, including (1) motivational enhancement therapy, (2) cognitive behavioral treatment, (3) adolescent community reinforcement approach, (4) multidimensional family therapy, and (5) family support network The Cannabis Youth Treatment Study showed that, while the initial interventions were often effective, half of the adolescents experienced intermittent relapse one or more times after discharge. Two-thirds still reported substance use or related problems at twelve-month follow-up. The researchers concluded that cannabis diagnoses are best understood as chronic conditions requiring a need to focus more on long-term monitoring and care. For adults with CUD, few programs specialize in marijuana-only treatment, but many programs provide competent outpatient or residential services, mostly consisting of individual, group, and twelve-step meetings. Physicians and certified counselors who specialize in addiction medicine are also good referral resources. In some communities, marijuana anonymous (MA) meetings may be available. For a national directory of available alcohol and drug detox and treatment programs, go to www.findtreatment.samhsa.gov or www.csam-asam.org/member/search. Click here to read part 2 -- Clinical Treatment of Cannibas Use Disorders in Adolescents Peter Banys, MD, MSc, is clinical professor of psychiatry at UCSF. Timmen Cermak, MD, is an addiction psychiatrist in private practice. Both are members of Lt. Governor Gavin Newsom's Blue Ribbon Commission on marijuana law reform. Comments are closed.
